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1.
J Palliat Med ; 23(2): 296-299, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31295046

RESUMO

Opioids have long been a mainstay of symptom management in palliative care (PC), allowing patients with terminal illnesses to have an improved quality of life. Unfortunately, these same medications have contributed to the explosion of the opioid epidemic. This article explores the case of a patient with opioid use disorder (OUD) and pancreatic cancer. We share our experience of managing his symptoms and treating OUD in the setting of an outpatient PC clinic. We explore the challenges and joys of this case while reflecting on the need for more research investigating best practices for individuals where opioids serve as both a pain reliever and contributor to further suffering from their OUD.

2.
J Am Geriatr Soc ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31840808

RESUMO

OBJECTIVES: Limited data suggest that a healthy diet is associated with a lower risk of frailty. We sought to assess the relationship between three measures of diet quality and frailty among male physicians. DESIGN: Cross-sectional analysis of a cohort study. SETTING: Physicians' Health Study. PARTICIPANTS: A total of 9861 initially healthy US men, aged 60 years or older, who provided data on frailty status and dietary habits. MEASUREMENTS: A cumulative deficit frailty index (FI) was calculated using 33 variables encompassing domains of comorbidity, functional status, mood, general health, social isolation, and change in weight. Diet quality was measured using the Alternative Healthy Eating Index (aHEI), Mediterranean Diet Score (MDS), and Dietary Approaches to Stop Hypertension (DASH). RESULTS: The FI identified 38% of physicians as non-frail, 44% as pre-frail, and 18% as frail. Multinomial logistic regression models adjusted for age, smoking status, and energy intake showed that compared with the lowest aHEI quintiles, those in the highest quintiles had lower odds of frailty and pre-frailty compared with non-frailty (odds ratio [OR] for frailty = .47; 95% confidence interval [CI] = .39-.58; for pre-frailty: OR = .75; CI = .65-.87). Exercise did not modify this association (P interaction >.1). Similar relationships were observed for DASH and MDS quintiles with frailty and pre-frailty. Restricted cubic splines showed an inverse dose-response relationship of diet quality scores with odds of frailty and pre-frailty. CONCLUSION: Cross-sectional data show an inverse dose-response relationship of diet quality with pre-frailty and frailty. Future longitudinal studies are needed to investigate whether healthier diet is a modifiable risk factor for frailty. ClinicalTrials.gov identifier: NCT00000500.

3.
Atherosclerosis ; 289: 51-56, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31450014

RESUMO

BACKGROUND: Walking pace is increasingly being used to assess functional status in ambulatory settings. METHODS: We conducted a prospective analysis within the Physicians' Health Study to examine whether walking pace is associated with mortality and incident cardiovascular disease (fatal or nonfatal myocardial infarction, coronary artery bypass grafting and percutaneous transluminal coronary angioplasty). Participants included 21,919 male physicians with a mean age of 67.8 ±â€¯9.0 years. RESULTS: After a median follow-up of 9.4 years (IQR: 7.9-10.3), 3906 deaths and 2487 incident CVD events occurred. In a multivariable Cox proportional hazards model adjusting for age, body mass index, smoking, exercise frequency, and prevalent hypertension, diabetes mellitus, heart failure, peripheral vascular disease, cancer, and total weekly walking time, hazard ratios for mortality were 0.72 (95% CI: 0.64-0.81) for walking pace of 2-2.9mph, 0.63 (95% CI: 0.55-0.73) for walking pace of 3-3.9mph and 0.63 (95% CI: 0.48-0.83) for walking pace of ≥4mph compared to the group that reported not walking regularly (p trend <0.0001). Similar findings were observed for incident CVD: HRs were 0.88 (95% CI: 0.75-1.03) for a walking pace of 2-2.9mph, 0.75 (95% CI: 0.63-0.89) for a walking pace of 3-3.9mph and 0.70 (0.53-0.94) for a walking pace of ≥4mph compared to the group that reported not walking regularly (p trend 0.0001). These associations persisted after excluding those who exercised regularly. CONCLUSION: We found that walking pace is inversely associated with risk of mortality and CVD among US male physicians.

4.
J Gen Intern Med ; 34(10): 2224-2231, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31264082

RESUMO

BACKGROUND: Evidence for the benefit of implantable cardioverter defibrillators (ICD) in preventing sudden cardiac death (SCD) in older adults is mixed; age alone may not predict benefit. Frailty may help identify patients in whom an ICD does not improve overall mortality risk. METHODS: Structured search of PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials on 1/31/2019, without language restriction, with terms for ICD, frailty, and mortality. Frailty was defined broadly using any validated single component (e.g., walking speed, weight loss) or multi-component tool (e.g., cumulative deficit index). Each study was assessed for quality and risk of bias. RESULTS: We identified and screened 2649 titles, reviewed 280 abstracts, and extracted 71 articles. Nine articles, including two RCTs, one prospective cohort, and six retrospective cohort studies met all criteria. The most common reason for exclusion was a lack of frailty definition. Frailty definitions were heterogeneous, including cumulative deficit models, low weight, and walking speed. Follow-up time for mortality differed: from days to > 6 years. All studies indicated that mortality was higher amongst individuals identified as frail, regardless of definition. In one RCT, slow walkers did not benefit from ICD therapy after 3 years. A cohort of 83,792 Medicare beneficiaries in an ICD registry reported higher 1-year mortality following ICD in those with frailty or dementia. Four studies reported an association between being underweight and increased mortality following ICD placement. CONCLUSION: Existing literature suggests that individuals with frailty may not benefit from ICD placement for primary prevention of SCD.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31355371

RESUMO

Background: Previous studies have demonstrated a strong inverse association between cancer and risk of Alzheimer's disease (AD). This study aimed to further investigate this association by examining measures of cognitive performance and neuroimaging. Methods: Neuropsychological (NP) test batteries consisting of quantitative measures of memory and executive function and volumetric brain magnetic resonance imaging (MRI) scans measuring brain and white-matter hyperintensity volumes were administered to 2,043 dementia-free participants (54% women) in the Framingham Heart Study (FHS) Offspring cohort from 1999-2005. History of cancer was assessed at examination visits and through hospital records. Linear regression was used to examine the association between cancer history and NP/MRI variables. Results: There were 252 and 1,791 participants with and without a previous history of cancer, respectively. Cancer survivors had an average time between diagnosis and NP/MRI exam of 9.8 years. History of any invasive cancer was associated with better executive function (Beta=0.16, p=0.04) but not memory function. Non-invasive cancer was not associated with any change in cognitive performance. Patients with prostate cancer had larger frontal brain volumes (Beta=4.13, p=0.03). Cancer history was not associated with any other MRI measure. Conclusions: We did not find any strong evidence linking cancer to cognitive or neuroimaging biomarkers that would explain a lower risk of subsequent AD, although a previous FHS study demonstrated a strong inverse association between cancer and risk of AD. Future work should examine the association between cancer and other biomarkers of AD as well as more sensitive metrics of AD-related brain aging markers.

6.
JAMA Netw Open ; 2(6): e195313, 2019 06 05.
Artigo em Inglês | MEDLINE | ID: mdl-31173122

RESUMO

Importance: Anorexia nervosa is recognized as an important cause of morbidity in young people. However, the risk of cancer in people with anorexia nervosa remains uncertain. Objective: To evaluate the association of anorexia nervosa with the risk of developing or dying of cancer. Data Sources: MEDLINE, Scopus, Embase, and Web of Science from database inception to January 9, 2019. Study Selection: Published observational studies in humans examining the risk of cancer in people with anorexia nervosa compared with the general population or those without anorexia nervosa. Studies needed to report incidence or mortality rate ratios (RRs). Data Extraction and Synthesis: Screening, data extraction, and methodological quality assessment were performed by at least 2 researchers independently. A random-effects model was used to synthesize individual studies. Heterogeneity (I2) was assessed and 95% prediction intervals (PIs) were calculated. Main Outcomes and Measures: All cancer incidence and cancer mortality associated with anorexia nervosa. Secondary outcomes were site-specific cancer incidence and mortality. Results: Seven cohort studies published in 10 articles (42 602 participants with anorexia nervosa) were included. Anorexia nervosa was not associated with risk of developing any cancer (4 studies in women; RR, 0.97; 95% CI, 0.89-1.06; P = .53; I2, 0%; 95% PI, 0.80-1.18; moderate confidence). Anorexia nervosa was associated with decreased breast cancer incidence (5 studies in women; RR, 0.60; 95% CI, 0.50-0.80; P < .001; I2, 0%; 95% PI, 0.44-0.83; high confidence). Conversely, anorexia nervosa was associated with increased risk of developing lung cancer (3 studies in women; RR, 1.50; 95% CI, 1.06-2.12; P = .001; I2, 0%; 95% PI, 0.19-16.46; low confidence) and esophageal cancer (2 studies in women; RR, 6.10; 95% CI, 2.30-16.18; P < .001; I2, 0%; low confidence). Conclusions and Relevance: Among people with anorexia nervosa, risk of developing cancer did not differ compared with the general population, but a significantly reduced risk of breast cancer was observed. Understanding the mechanisms underlying these associations could have important preventive potential.


Assuntos
Anorexia Nervosa/complicações , Neoplasias/mortalidade , Adulto , Idoso , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/etiologia , Distribuição por Sexo , Adulto Jovem
7.
Blood ; 134(4): 374-382, 2019 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-31167800

RESUMO

This study aimed to evaluate whether gait speed and grip strength predicted clinical outcomes among older adults with blood cancers. We prospectively recruited 448 patients aged 75 years and older presenting for initial consultation at the myelodysplastic syndrome/leukemia, myeloma, or lymphoma clinic of a large tertiary hospital, who agreed to assessment of gait and grip. A subset of 314 patients followed for ≥6 months at local institutions was evaluated for unplanned hospital or emergency department (ED) use. We used Cox proportional hazard models calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for survival, and logistic regression to calculate odds ratios (ORs) for hospital or ED use. Mean age was 79.7 (± 4.0 standard deviation) years. After adjustment for age, sex, Charlson comorbidity index, cognition, treatment intensity, and cancer aggressiveness/type, every 0.1-m/s decrease in gait speed was associated with higher mortality (HR, 1.20; 95% CI, 1.12-1.29), odds of unplanned hospitalizations (OR, 1.33; 95% CI, 1.16-1.51), and ED visits (OR, 1.34; 95% CI, 1.17-1.53). Associations held among patients with good Eastern Cooperative Oncology Group performance status (0 or 1). Every 5-kg decrease in grip strength was associated with worse survival (adjusted HR, 1.24; 95% CI, 1.07-1.43) but not hospital or ED use. A model with gait speed and all covariates had comparable predictive power to comprehensive validated frailty indexes (phenotype and cumulative deficit) and all covariates. In summary, gait speed is an easily obtained "vital sign" that accurately identifies frailty and predicts outcomes independent of performance status among older patients with blood cancers.


Assuntos
Marcha , Avaliação Geriátrica , Força da Mão , Neoplasias Hematológicas/epidemiologia , Velocidade de Caminhada , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Idoso Fragilizado , Fragilidade , Neoplasias Hematológicas/diagnóstico , Neoplasias Hematológicas/mortalidade , Neoplasias Hematológicas/terapia , Humanos , Estimativa de Kaplan-Meier , Masculino , Avaliação de Resultados da Assistência ao Paciente , Vigilância em Saúde Pública
8.
J Am Geriatr Soc ; 67(7): 1502-1507, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31081946

RESUMO

OBJECTIVES: Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. DESIGN: We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. SETTING: The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. PARTICIPANTS: Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. MEASUREMENTS: A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis. RESULTS: Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89). CONCLUSION: The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.

9.
Psychooncology ; 28(7): 1551-1558, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31134710

RESUMO

OBJECTIVE: This study examines the demographic and clinical variables associated with cancer-related cognitive impairment (CRCI) in a sample of older, male, oral-digestive cancer survivors at VA Medical Centers in Boston and Houston. METHODS: A two-time point, longitudinal design was used, with cognitive assessment conducted at 6 and 18 months post-diagnosis. Using ANCOVA, the cognitive functioning of 88 older adults with head and neck, esophageal, gastric, or colorectal cancers was compared with that of 88 healthy controls. Paired t-tests examined cognitive change over time in the cancer group. Hierarchical linear regression examined variables potentially associated with cognitive impairment at 18 months. RESULTS: Forty-eight percent of cancer patients exhibited cognitive impairment 6 months post-cancer diagnosis, and 40% at 18 months. Cancer survivors were impaired relative to controls on measures of sustained attention, memory, and verbal fluency at 18 months, controlling for age. Older age, low hemoglobin, and cancer-related PTSD were associated with worse cognition at 18 months. CONCLUSIONS: CRCI is more frequent in older adults than reported in studies of younger adults and may be more frequent in men. Potential areas of intervention for CRCI include psychotherapy for cancer-related PTSD, treatment of anemia, and awareness of particularly vulnerable cognitive domains such as sustained attention, memory, and verbal fluency.

10.
J Am Geriatr Soc ; 67(5): 889-897, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30945759

RESUMO

BACKGROUND/OBJECTIVES: Cancer-focused organizations now recommend routine assessment of instrumental activities of daily living (iADLs) for all older patients with cancer, along with assessment of basic activities of daily living (ADLs) if possible. However, little is known regarding the role of iADLs in predicting survival and acute-care utilization in populations of older adults with different hematologic malignancies. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: A screening geriatric assessment was conducted for adults 75 years and older with hematologic malignancies (n = 464) presenting for initial consultation at a large tertiary cancer hospital in Boston, MA. MEASUREMENTS: Univariable and multivariable analyses assessed the association of dependency in ADLs and dependency in iADLs with survival and care utilization (emergency department [ED] visits and unplanned hospitalizations). RESULTS: Subjects were a mean age of 79.7 years and had a mean follow-up of 13.8 months. Overall, 11.4% had dependency in ADLs and 26.7% had dependency in iADLs. Only iADL dependency was associated with higher mortality (hazard ratio = 2.34 [95% confidence interval [CI] = 1.46-3.74]) independently of age, comorbidity, cancer aggressiveness, and treatment intensity. The effect was dose dependent, and impairments in shopping, meal preparation, and housework were all independently associated with a higher hazard of death. iADL dependency was also associated with higher odds of ED visits (odds ratio [OR] = 2.76 [95% CI = 1.30-5.84]) and hospitalizations (OR = 2.89 [95% CI = 1.37-6.09]). Several geriatric domain impairments, including probable cognitive impairment and physical dysfunction, were associated with iADL dependency. CONCLUSION: These findings suggest that older adults with hematologic malignancies and iADL dependency experience higher mortality and acute-care utilization, arguing that iADLs should be formally assessed as part of routine oncology care. J Am Geriatr Soc 67:889-897, 2019.

11.
Hum Genet ; 138(3): 271-285, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30805717

RESUMO

A growing number of studies clearly demonstrate a substantial link between metabolic dysfunction and the risk of Alzheimer's disease (AD), especially glucose-related dysfunction; one hypothesis for this comorbidity is the presence of a common genetic etiology. We conducted a large-scale cross-trait GWAS to investigate the genetic overlap between AD and ten metabolic traits. Among all the metabolic traits, fasting glucose, fasting insulin and HDL were found to be genetically associated with AD. Local genetic covariance analysis found that 19q13 region had strong local genetic correlation between AD and T2D (P = 6.78 × 10- 22), LDL (P = 1.74 × 10- 253) and HDL (P = 7.94 × 10- 18). Cross-trait meta-analysis identified 4 loci that were associated with AD and fasting glucose, 3 loci that were associated with AD and fasting insulin, and 20 loci that were associated with AD and HDL (Pmeta < 1.6 × 10- 8, single trait P < 0.05). Functional analysis revealed that the shared genes are enriched in amyloid metabolic process, lipoprotein remodeling and other related biological pathways; also in pancreas, liver, blood and other tissues. Our work identifies common genetic architectures shared between AD and fasting glucose, fasting insulin and HDL, and sheds light on molecular mechanisms underlying the association between metabolic dysregulation and AD.


Assuntos
Doença de Alzheimer/diagnóstico , Doença de Alzheimer/genética , Metabolismo Energético/genética , Predisposição Genética para Doença , Estudo de Associação Genômica Ampla , Característica Quantitativa Herdável , Doença de Alzheimer/metabolismo , Glicemia , Jejum , Estudos de Associação Genética , Humanos , Insulina/sangue , Desequilíbrio de Ligação , Redes e Vias Metabólicas , Fenótipo , Locos de Características Quantitativas
12.
Arch Phys Med Rehabil ; 100(5): 995-1000, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30735624

RESUMO

Older adults are the fastest growing segment of our population and contribute greatly to the high costs of health care. The primary concern among older adults seeking health care is maintaining or improving functional independence. This concern is the focus of both rehabilitative care and geriatric medicine; however, collaboration between these fields can be hampered by a lack of mutual understanding of the fundamental principles of the other field. We describe 3 steps that can be implemented at an organizational or individual level to bridge the fields of geriatric medicine and rehabilitation, allowing them to better serve older patients. These include (1) recognizing the interwoven concepts of multimorbidity, function, and frailty; (2) communicating with a common language; and (3) synthesizing our knowledge from both fields.


Assuntos
Geriatria , Comunicação Interdisciplinar , Reabilitação , Idoso , Comorbidade , Fragilidade/fisiopatologia , Humanos , Bases de Conhecimento , Terminologia como Assunto
13.
J Gerontol A Biol Sci Med Sci ; 74(3): 373-379, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-29917058

RESUMO

BACKGROUND: Frailty is a risk factor for cardiovascular disease (CVD). Underlying mechanisms to explain the connection between frailty and CVD are unclear. We sought to examine the association between frailty and arterial stiffness, a precursor of hypertension and CVD. METHODS: We conducted a cross-sectional analysis of community-dwelling Framingham Heart Study Offspring and Omni participants ≥60 years of age examined in 2005-2008. Frailty was defined primarily according to the Fried physical phenotype definition, which identifies nonfrail, prefrail, and frail individuals. Arterial stiffness was assessed using carotid-femoral pulse wave velocity (CFPWV). Generalized linear regression was used to examine the association between frailty level and CFPWV (modeled as -1000/CFPWV in msec/m, then transformed back to the original scale, m/s), adjusted for age, sex, cohort, mean arterial pressure, heart rate, height, and smoking. RESULTS: Of 2,171 participants (55% women, 91% white), 45% were prefrail and 7% were frail. Mean ages were 67, 70, and 73 years, and adjusted CFPWV least squares means were 10.0 (95% CI, 9.9-10.1), 10.3 (10.2-10.5), and 10.5 m/s (10.1-11.0); p = .0002 for nonfrail, prefrail, and frail groups, respectively. Results were similar using the Rockwood cumulative deficit model of frailty, and in a sensitivity analysis adjusting for prevalent coronary heart disease and diabetes. CONCLUSIONS: Prefrailty and frailty were associated with higher arterial stiffness in a cohort of community-dwelling older adults. Arterial stiffness may help explain the relationship between frailty and CVD.


Assuntos
Fragilidade/complicações , Fragilidade/fisiopatologia , Rigidez Vascular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Fragilidade/diagnóstico , Humanos , Vida Independente , Modelos Lineares , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise de Onda de Pulso
14.
J Gerontol A Biol Sci Med Sci ; 74(8): 1257-1264, 2019 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-30307533

RESUMO

BACKGROUND: Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality. METHODS: Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002-2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality. RESULTS: A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0-0.10), 32.6% were pre-frail (FI = 0.11-0.20), 18.9% were mildly frail (FI = 0.21-0.30), 8.7% were moderately frail (FI = 0.31-0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years' hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97-2.04), 3.49 (3.44-3.55), 5.88 (5.79-5.97), and 10.39 (10.23-10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49-1.53), 2.36 (2.33-2.39), 3.68 (3.63-3.73), 6.62 (6.53-6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites. CONCLUSIONS: Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.

15.
J Geriatr Oncol ; 10(3): 486-489, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30472368

RESUMO

OBJECTIVES: We compared the performance of two frailty scoring systems in predicting survival among older patients with multiple myeloma: the International Myeloma Working Group (IMWG) frailty score (which includes age), and the Fried model for frailty (which does not). METHODS: From 2015 to 2018, all patients aged 75 years and older presenting at our institution with a diagnosis of multiple myeloma were approached for a frailty screening assessment. We first categorized patients' frailty using the Fried model. Then, using available deficit measures, we reclassified frailty using the IMWG approach. We compared the performance of the IMWG strategy to the Fried model in terms of association with overall survival. RESULTS: Of the 98 (92%) patients who consented to a baseline frailty assessment, we found 57% discordance among frailty classification between the two scoring systems. Using the IMWG strategy, 9% of the cohort was "fit," 29% "intermediate-fit," and 62% "frail." Using the Fried model, 29% of the cohort was "robust," 52% "pre-frail," and 19% "frail." Frailty category in the Fried model was predictive of overall survival among our cohort, while frailty category in the IMWG strategy was not (log-rank p = 0.04 vs. 0.34). CONCLUSION: Among our cohort of older patients with myeloma (aged 75 and higher), the Fried model appears to be a better predictor of survival compared to the IMWG strategy. These results suggest that using age as a criterion to identify frailty in older patients with multiple myeloma may limit treatment options for the functionally vigorous.

18.
Curr Aging Sci ; 11(2): 77-89, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29552989

RESUMO

BACKGROUND: A growing body of epidemiologic evidence suggests that neurodegenerative diseases occur less frequently in cancer survivors, and vice versa. While unusual, this inverse comorbidity is biologically plausible and could be explained, in part, by the evolutionary tradeoffs made by neurons and cycling cells to optimize the performance of their very different functions. The two cell types utilize the same proteins and pathways in different, and sometimes opposite, ways. However, cancer and neurodegeneration also share many pathophysiological features. OBJECTIVE: In this review, we compare three overlapping aspects of neurodegeneration and cancer. METHOD: First, we contrast the priorities and tradeoffs of dividing cells and neurons and how these manifest in disease. Second, we consider the hallmarks of biological aging that underlie both neurodegeneration and cancer. Finally, we utilize information from genetic databases to outline specific genes and pathways common to both diseases. CONCLUSION: We argue that a detailed understanding of the biologic and genetic relationships between cancer and neurodegeneration can guide future efforts in designing disease-modifying therapeutic interventions. Lastly, strategies that target aging may prevent or delay both conditions.


Assuntos
Envelhecimento , Transformação Celular Neoplásica , Neoplasias , Doenças Neurodegenerativas , Neurônios , Fatores Etários , Envelhecimento/genética , Envelhecimento/metabolismo , Envelhecimento/patologia , Animais , Proliferação de Células , Transformação Celular Neoplásica/genética , Transformação Celular Neoplásica/metabolismo , Transformação Celular Neoplásica/patologia , Senescência Celular , Comorbidade , Regulação Neoplásica da Expressão Gênica , Humanos , Neoplasias/epidemiologia , Neoplasias/genética , Neoplasias/metabolismo , Neoplasias/patologia , Degeneração Neural , Doenças Neurodegenerativas/epidemiologia , Doenças Neurodegenerativas/genética , Doenças Neurodegenerativas/metabolismo , Doenças Neurodegenerativas/patologia , Neurônios/metabolismo , Neurônios/patologia , Fatores de Proteção , Fatores de Risco , Transdução de Sinais
19.
JAMA Oncol ; 4(5): 686-693, 2018 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-29494732

RESUMO

Importance: As the population ages, cognitive impairment has promised to become increasingly common among patients with cancer. Little is known about how specific domains of cognitive impairment may be associated with survival among older patients with hematologic cancers. Objective: To determine the prevalence of domain-specific cognitive impairment and its association with overall survival among older patients with blood cancer. Design, Setting, and Participants: This prospective observational cohort study included all patients 75 years and older who presented for initial consultation in the leukemia, myeloma, or lymphoma clinics of a large tertiary hospital in Boston, Massachusetts, from February 1, 2015, to March 31, 2017. Patients underwent screening for frailty and cognitive dysfunction and were followed up for survival. Exposures: The Clock-in-the-Box (CIB) test was used to screen for executive dysfunction. A 5-word delayed recall test was used to screen for impairment in working memory. The Fried frailty phenotype and Rockwood cumulative deficit model of frailty were also assessed to characterize participants as robust, prefrail, or frail. Results: Among 420 consecutive patients approached, 360 (85.7%) agreed to undergo frailty assessment (232 men [64.4%] and 128 women [35.6%]; mean [SD] age, 79.8 [3.9] years), and 341 of those (94.7%) completed both cognitive screening tests. One hundred twenty-seven patients (35.3%) had probable executive dysfunction on the CIB, and 62 (17.2%) had probable impairment in working memory on the 5-word delayed recall. Impairment in either domain was modestly correlated with the Fried frailty phenotype (CIB, ρ = 0.177; delayed recall, ρ = 0.170; P = .01 for both), and many phenotypically robust patients also had probable cognitive impairment (24 of 104 [23.1%] on CIB and 9 of 104 [8.7%] on delayed recall). Patients with impaired working memory had worse median survival (10.9 [SD, 12.9] vs 12.2 [SD, 14.7] months; log-rank P < .001), including when stratified by indolent cancer (log-rank P = .01) and aggressive cancer (P < .001) and in multivariate analysis when adjusting for age, comorbidities, and disease aggressiveness (odds ratio, 0.26; 95% CI, 0.13-0.50). Impaired working memory was also associated with worse survival for those undergoing intensive treatment (log-rank P < .001). Executive dysfunction was associated with worse survival only among patients who underwent intensive treatment (log-rank P = .03). Conclusions and Relevance: These data suggest that domains of cognitive dysfunction may be prevalent in older patients with blood cancer and may have differential predictive value for survival. Targeted interventions are needed for this vulnerable patient population.


Assuntos
Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Neoplasias Hematológicas/complicações , Neoplasias Hematológicas/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biomarcadores , Disfunção Cognitiva/mortalidade , Comorbidade , Feminino , Neoplasias Hematológicas/mortalidade , Humanos , Masculino , Memória de Curto Prazo , Prevalência , Prognóstico , Análise de Sobrevida
20.
Cleve Clin J Med ; 85(1): 55-64, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29328899

RESUMO

Frailty and cardiovascular disease are highly interconnected and increase in prevalence with age. Identifying frailty allows for a personalized cardiovascular risk prescription and individualized management of hypertension, hyperlipidemia, diabetes, and lifestyle in the aging population.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Idoso Fragilizado , Fragilidade/complicações , Medicina de Precisão/métodos , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/etiologia , Diabetes Mellitus , Feminino , Avaliação Geriátrica , Humanos , Hiperlipidemias/complicações , Hipertensão/complicações , Estilo de Vida , Masculino , Fatores de Risco
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